Composite grafting for eyelid reconstruction

A Single Staged Reconstruction of Upper Eyelid and Eyelashes

The upper eyelid is a complex structural part of the face that plays an important role in protecting the cornea from drying and damage to preserve vision. The eyelashes are an essential part of the upper eyelid and help in protecting the eyes from dust, foreign bodies, and sweat. Being a part of the face, which is the most noticeable part of the body, both structures hold an important role in reconstructive procedures. Reconstruction of both structures simultaneously is tricky but helps reduce the number of procedures required in achieving an aesthetically acceptable eye. Our techniques describe the use of the paramedian forehead flap with an anterior hairline to reconstruct the upper eyelid and eyelashes in a single stage in a posttraumatic near-total upper eyelid defect with a favorable outcome. Depending on the parting of the patient's hair, the anterior hairline of one side can be included in the distal edge of the flap while raising, which can be inset so that the direction and orientation of the eyelashes perfectly match. Our technique refurbishes an established technique for eyelid reconstruction to include eyelash reconstruction at the same time, thus saving time and resources without any inconvenience to the patient.

One-step repair of a large congenital upper eyelid coloboma using a bilamellar graft in an infant: a case report and literature review

Large congenital lid colobomas are traditionally repaired using 1- or 2-step vascularized flap-graft combinations. However, visual axis occlusion for weeks is a severe problem in small children and recent reports suggest that the flap pedicle does not contribute to blood perfusion. A "one-step" substitute for large lid defects has recently been reported in animals and humans, demonstrating the viability of a bilamellar autograft alone. We present an alternative "one-step" reconstructive approach in a 6-month-old infant who had a centrally-located large upper eyelid defect resulting from a congenital coloboma. The free full-thickness bilamellar autograft was harvested from the contralateral upper eyelid. The follow-up time was 48 months. Cosmetic and functional results were good, the bilamellar graft survived, and there was no graft ischemia, necrosis, or rejection. The boy developed madarosis, lid notching, and mild contour irregularity but needed no reoperation since the parent was satisfied with the surgical result. A free bilamellar eyelid autograft seems to be an outstanding alternative to both "conventional 2-step" and "modern 1-step" options for the reconstruction of large colobomatous eyelid openings, especially in young infants who cannot tolerate visual axis blockage. It is an easy, practical, fast, and effective technique that also saves cost in health care.

Perfusion Monitoring During Oculoplastic Reconstructive Surgery: A Comprehensive Review

PURPOSE

Knowledge of how blood perfusion is affected during and after reconstructive surgery is of great importance to predict the survival of grafts and flaps. When commonly used reconstructive procedures were developed a century ago, they were based on empirical observations of clinical outcome.

METHODS

This is a comprehensive literature review that summarizes the current state of knowledge regarding microvascular perfusion monitoring during oculoplastic procedures.

RESULTS

Over the years, a number of techniques for perfusion monitoring have been developed as an attempt to be more objective than clinical examination using traditional methods such as observations of skin temperature, turgor, color, smell, and capillary refill time. There are limited publications regarding microvascular perfusion monitoring during reconstructive procedures in the periocular area. Modern laser-based techniques have been attractive due to their noninvasive nature.

CONCLUSIONS

Today, modern, noninvasive techniques are available to monitor perfusion during and after surgery. This has increased our knowledge on the perfusion in common oculoplastic surgery procedures. A detailed understanding of how blood perfusion is affected will hopefully allow the improvement of surgical techniques for better clinical outcome.

Successful Free Bilamellar Eyelid Grafts for the Repair of Upper and Lower Eyelid Defects in Patients and Laser Speckle Contrast Imaging of Revascularization

PURPOSE

It is generally believed that large eyelid defects must be repaired using a vascularized flap for 1 lamella, while the other can be a free graft. Recent studies indicate that the pedicle of a tarsoconjunctival flap does not contribute to blood perfusion. The purpose of this study was to explore whether large eyelid defects can be repaired using a free bilamellar eyelid autograft alone.

METHODS

Ten large upper and lower eyelid defects resulting from tumor excision were reconstructed using bilamellar grafts harvested from the contralateral or opposing eyelid. Revascularization of the flap was monitored during healing using laser speckle contrast imaging, and the surgical outcome was assessed.

RESULTS

The functional and cosmetic results were excellent. All grafts survived and there was no tissue necrosis. Only 1 patient underwent revision after 4 days as the sutures came loose. Two patients developed minimal ectropion but needed no reoperation. All patients were satisfied with the surgical results. Perfusion monitoring showed that the grafts were gradually revascularized, exhibiting 50% perfusion after 4 weeks and 90% perfusion after 8 weeks.

CONCLUSIONS

A free bilamellar eyelid graft appears to be an excellent alternative to the tarsoconjunctival flap procedure in the reconstruction of both upper and lower eyelid defects, especially in patients who cannot tolerate visual axis occlusion or the 2-stage procedure of the conventional staged flap procedure.

Single-stage repair of large full thickness lower eyelid defects using free tarsoconjunctival graft and transposition flap: experience and outcomes

Background: Lid-sharing approaches are often advocated for repair of large full thickness lower eyelid defects, however result in temporary visual obstruction and the need for a second-stage procedure. The authors describe and report outcomes using a one-stage technique utilizing a free tarsoconjunctival graft (TCG) and musculocutaneous transposition flap (MCT) to repair defects up to 90% of the lower eyelid.Methods: A retrospective chart review on patients that had undergone full thickness lower eyelid reconstruction using a TCG and MCT between the dates of 1/1/2015 to 3/1/2020 was performed. Demographic and clinical information including indication for repair, size of defect, post-operative complications, and outcomes were recorded and analyzed.Results: Six cases of lower eyelid reconstruction using this technique were identified. Fifty percent were male, average age was 61.3 years (range 36-91, SD = 18.9), and follow up was 36.7 weeks (range 3-129, SD = 48.1). All defects were due to malignancy (4/6 for basal cell carcinoma, 1/6 each for sebaceous cell carcinoma and merkel cell carcinoma). Average horizontal defect size was 80% of lower eyelid width (range 57%-90%, SD = 12.3), while average vertical defect size was 8 mm (range 5-10 mm, SD = 1.7). There were no instances of post-operative infection, lid malposition, or dehiscence. A pyogenic granuloma was noted in one case and was managed with excision.Conclusion: A single-stage procedure using a TCG and MCT can be used to repair laterally based full-thickness lower eyelid defects up to 90% with satisfactory outcomes and few complications.

Repair of a Full-thickness Eyelid Defect With a Bilamellar Full-thickness Autograft in a Porcine Model (Sus scrofa)

PURPOSE

It has been demonstrated the pedicle of a tarsoconjunctival flap advancement does not appear to supply the flap itself and the vascularization of the remaining eyelid/tear film is thought to offer adequate nourishment for survival of the flap; as such, a swine model was constructed to assess the viability of a bilamellar autograft for repair of large full-thickness eyelid defects.

METHODS

Full-thickness defects of varying sizes were created in each lower eyelid of 4 Yorkshire/Yorkshire crossed swine. The defects were then closed with a full-thickness ipsilateral graft from the upper eyelid. Large full-thickness defects were then created in the upper and lower eyelids of 8 Yorkshire/Yorkshire crossed swine and closed with bilamellar autografts from the contralateral eyelids. The subjects were then monitored postoperatively and assessed clinically for graft viability at postoperative days 1, 7, and 30. At the conclusion of the 30-day postoperative monitoring period, necropsy was performed and histopathologic analysis utilized to assess cell morphology and vessel ingrowth of the graft sites.

RESULTS

In total, 28 full-thickness bilamellar grafts were constructed and examined. At the conclusion of the postoperative monitoring period, 27 of the grafts were deemed clinically viable and vascular ingrowth was determined to be equivalent to unaffected eyelid sections by histopathologic analysis. One case of postoperative hematoma was noted in the failed graft. One case of postoperative wound dehiscence required subsequent surgical repair. No clinically significant notching of the graft sites was noted. No cases of wound infection, corneal decompensation, or forniceal shortening were identified.

CONCLUSIONS

This analysis demonstrates the viability of a full-thickness bilamellar autograft as a surgical alternative in the repair of large full-thickness eyelid defects in a porcine model. The postoperative outcomes are consistent with the recent literature. Additional studies need to be performed to assess the procedure's clinical utility in human subjects before incorporation into clinical practice.

Hübner's tarsomarginal grafts in eyelid reconstruction: 94 cases

BACKGROUND

Preserving the integrity of the eyelid margin in eyelid reconstruction remains a challenge for plastic surgeons. In 1976, Hübner described a technique to repair full-thickness eyelid defects using a tarsomarginal graft covered with a local flap. This simple technique addresses both functional and aesthetic requirements of eyelid reconstruction by using tissue from the contralateral eyelid. The aim of this study was to determine the appropriate role of this uncommon technique in eyelid reconstruction.

METHOD

In total, 94 tarsomarginal grafts were performed on 70 patients. Eight surgeons participated in this study. Data were retrospectively collected from patients' charts and all information regarding surgical indications, histology, defect size and topography, operative time, immediate result, and potential complications were recorded.

RESULTS

Only one of the patients suffered total necrosis. Partial wound dehiscence occurred in one case and partial necrosis occurred in 6 cases. No major sequelae were observed in the donor eyelids. In 100% of cases, eyelid margin integrity was otherwise preserved. Four patients required revision surgery for insufficient malignancy resection and 13 patients for long-term eyelid ectropion or scar retraction.

CONCLUSION

This simple and reliable technique ensured the closure of full-thickness eyelid defects covering up to 3/4 of the eyelid length. The procedure should be more widely used as it guarantees high-quality eyelid reconstruction.

Hübner's eyelid reconstruction using a free tarsomarginal autograft in eight dogs. A retrospective study

OBJECTIVE

The aim of our work was to study the potential of tarsomarginal grafting technique, in canine.

ANIMAL STUDIED

All dogs included in this study had tumors of the upper or lower eyelid. Furthermore, resection of the tumor necessitated excision of the eyelid margin comprising 1/4 and 2/3.

PROCEDURE

Harvesting of the graft with the length of half the length of the tumor, including its free margins was performed via a full-thickness incision on the ipsilateral healthy eyelid. The cutaneous layer and all of the muscle fibers of the transplant were meticulously removed except a 3 mm strip along the free lid margin. A full-thickness tumor excision was then performed. The graft was sutured at the level of the defect to be reconstructed. A sliding H flap was generated. The resulting nourishing myocutaneous flap was then sutured along the free margin of the tarso-conjunctivo-marginal graft. The lateral edges of the advancement flap were sutured to the edges of the receiving sites.

RESULTS

The average size of the reconstructed area was 17.8 mm. The resulting stretched lid fissure length after surgery was shortened over 7 to 11 mm. This technique for grafting was used to reconstruct an eyelid that had lost tissue measuring between 1/4 and 2/3 of its length. The few complications that were encountered were mainly the occurrence of keratitis or suture dehiscence.

CONCLUSIONS

This tarsomarginal grafting technique has yielded encouraging results in dogs. This technique can fill large lid defects with a physiologic lid margin but is shortening the stretched lid fissure length.

Repair of 50-75% full-thickness lower eyelid defects: Lateral stabilization as a guiding principle

Introduction:

Repair of large defects of the lower eyelid can be difficult. A common procedure performed to address these defects is a Hughes flap. This procedure has a number of disadvantages: The eye is closed postoperatively, a second stage is required, and the edge of the flap is often erythematous. The purpose of this paper is to describe a one-stage procedure for the repair of large full-thickness defects of the lower lid as an alternative to a Hughes flap.

Materials and Methods:

This is a retrospective study of patients who underwent the described procedure. The procedure employs lateral stabilization of the posterior lamella with a periosteal strip, medial transposition of the lateral posterior lamella for central and medial defects, and a myocutaneous advancement flap to stabilize the anterior lamella.

Results:

A total of 38 patients underwent the procedure to reconstruct full-thickness defects of the lower lid ranging from 50% to 75%. All patients underwent previous Mohs excision of a skin cancer. The average follow-up was 5.6 months. Eleven patients (29%) had postoperative sequelae, but only two patients (5%) required additional treatment.

Conclusion:

Lateral stabilization with a periosteal strip and myocutaneous advancement flap is an excellent one-step procedure that avoids many of the complications seen with the Hughes procedure and is comparable to other techniques used for the reconstruction of subtotal, full-thickness lower lid defects.

Free tarsomarginal graft for large congenital coloboma repair in patients with Tessier number 10 clefts

AIM

The aim of this study was to evaluate the long-term outcome when a free tarsomarginal graft is used to repair a large congenital coloboma in patients with a Tessier number 10 cleft.

MATERIALS AND METHODS

This was a retrospective, interventional case series. The medical records were reviewed for five children (six eyes) diagnosed as having Tessier number 10 cleft with large upper eyelid defects and symblepharon. These children were referred to the Department of Ophthalmology of Shanghai Ninth People's Hospital, between May 2007 and December 2012. Reconstructive techniques included repair of the upper eyelid defect with a free tarsomarginal graft taken from the lower eyelid, and reconstruction of the conjunctival fornix by using a conjunctival autograft after symblepharon lysis. All the children were followed up for more than 2 years. Postoperative upper eyelid contour, viability and function for corneal protection, and recurrence of symblepharon were assessed.

RESULTS

A one-stage reconstruction procedure was used in all children. All reconstructed eyelids achieved a surgical goal of providing corneal protection and improved cosmesis, with marked improvement of exposure keratopathy and no associated lagophthalmos. Adequate reconstruction of the upper fornix was obtained, and there was no obvious recurrence of symblepharon.

CONCLUSION

A free tarsomarginal graft is beneficial and seems to be an adequate method for reconstruction of large eyelid defects in children with a Tessier number 10 cleft. Symblepharon lysis with a conjunctival autograft for reconstruction of the ocular surface can be performed at the same time as eyelid repair as a one-stage procedure.

Congenital upper eyelid coloboma: embryologic, nomenclatorial, nosologic, etiologic, pathogenetic, epidemiologic, clinical, and management perspectives

Purpose:

To review the recent literature and describe the authors’ experience with congenital upper eyelid coloboma.

Methods:

In this review, we will summarize the embryologic and etiopathogenetic bases of congenital upper eyelid coloboma, and study the published clinical reports. We will also attempt to briefly shed some light on the rarer syndromic curiosities associated with upper eyelid coloboma.

Results:

Congenital upper eyelid colobomas are one of the few nontraumatic oculoplastic emergencies that may occasionally present in the first few days of life with a corneal ulcer and may even present with impending perforation. They can present with or without corneopalpebral adhesions, may be isolated findings or a part of a larger spectrum of congenital anomalies as in the case of Fraser syndrome or Goldenhar syndrome, or could be associated with other rare curiosities that could challenge the clinician with a huge diagnostic dilemma.

Conclusions:

Existing literature dealing with congenital colobomas of the upper eyelid is fraught with nosologic problems, confusing etiologies, and overlapping clinical features. We attempted to clarify the salient clinical features, outline the management principles, and until a time in the not-so-distant future where advances in molecular genetic testing would help redefine the etiology and the diverse clinical spectrum of genetic diseases associated with upper eyelid colobomas, we propose a simplified classification scheme based on the relation of the coloboma to the cornea, the presence or absence of systemic features, and all the syndromic and nonsyndromic associations of congenital coloboma of the upper eyelid known today.

In this review, the authors will describe the pathogenesis of upper eyelid coloboma, suggest a new simplified classification system, describe the clinical picture in detail, clarify the various syndromic associations of upper eyelid coloboma, and lay out the basic surgical principles of management.

Management of the large upper eyelid defects with cutler-beard flap

Background. To assess Cutler-Beard procedure results in patients after wide excision of malignant eyelid tumours. Materials and Methods. The records of two women and two men (four patients) referred to our clinic with eyelid mass complaints and malign eyelid tumour diagnosis according to the histopathological examination were examined retrospectively. Results. The patients were 60–73 years old and their average age was 66 ± 11.10. The follow-up period of the cases was 16 (6–25) months. Total excisional biopsy was applied to all patients and then Cutler-Beard full thickness lid reconstruction was done because of the wide localization of the tumour. The patients' diagnoses were consistent with basal cell carcinoma, sebaceous gland carcinoma, eyelid lymphoma, and squamous cell carcinoma. The patients' eyelids were separated from each other 1 month postoperatively with a second operation. Superior eyelid entropium and blepharochalasis were seen in one patient during followup. Conclusions. Cutler-Beard flap is a successful procedure for superior eyelid tumours accompanied by wide tissue loss. The long-time closure of the eyelids and the need for secondary surgery are the major disadvantages of this procedure. Our experience with this procedure will reveal better results with large case series.

Orbicularis oculi myocutaneous island flap for upper eyelid reconstruction

The cosmetic and functional outcomes of a reconstruction of an upper eyelid defect due to trauma or neoplasm are very important. This article reports the technique of an orbicularis oculi myocutaneous island flap for covering small- to moderate-sized defects of the upper eyelid. Between March 2008 and March 2010, 5 patients underwent surgery for an upper eyelid reconstruction. After tumor excision and debridement, the eyelid margin was closed directly before the reconstruction. The flap was designed just beside the defect considering the amount of tissue remaining for the reconstruction. The flap was elevated by splitting the muscle by the direction of its fibers without damaging the pedicle. The elevated flap was then transposed to the defect without tension.The orbicularis oculi myocutaneous flap is a single-stage reconstruction with reliable vascularity. It can be used to cover a defect without compromising the primary closure of the donor site and can be customized to reconstruct the defect with minimal tissue. Therefore, an orbicularis oculi myocutaneous island flap can be an alternative for a single-stage reconstruction of small- to moderate-sized defects of the upper eyelid.

[Eyelid reconstruction according to Hübner's technique: About the use of 12 tarsomarginal grafts]

PURPOSE

The repair of full-thickness eyelid defect must fulfill multiple surgical requirements that are determined by the anatomical and functional features of the eyelids. Many reconstructive procedures are available, each and anyone of them presenting their own peculiar goals and constraints. Among them, we have tried to determine the place and the reliability of Hübner's tarsomarginal grafts.

PATIENTS AND METHOD

Through a retrospective study of 11 patients treated with 12 grafts, over a period of 3 years, we evaluated our indications, technical principles and results of this procedure.

RESULTS

The full-thickness eyelid defects represented between one quarter and three quarter of the marginal border length. They principally resulted from malignant tumors resection. In most of the cases, their management required a single graft, harvested on the contralateral homologous eyelid. Complications were minor and rare. Functional and aesthetical results were satisfactory. There was no functional sequel on the donor site.

CONCLUSION

Tarsomarginal grafts in eyelid reconstruction provide multiple advantages. With this simple and versatile technique, wide and complex eyelid repairs can be managed in a one-step surgery. This procedure is very reliable; it gives good functional and aesthetical results. Hübner's technique is a major tool in eyelid reconstructive surgery.

Tarsomarginal graft in upper eyelid coloboma repair

Eyelid colobomas are congenital defects caused by failure of fusion of the mesodermal lid folds. The timing and approach to surgical repair depend on the severity of the defect and exposure keratopathy. Tarsomarginal grafts have been well described in eyelid reconstructions following tumor excision. Descriptions of lid coloboma repair using this approach are limited. We describe a series of upper lid colobomas repaired with the tarsomarginal graft.

Trichiasis After Eyelash Augmentation With Hair Follicle Transplantation

Eyelash loss has many causes. The absence of lashes is frequently cosmetically objectionable for patients. Many techniques have been used to improve cosmesis, including tattooing and transplantation of cilia. This is a report on the result of individual hair follicle transplantation to the upper eyelids with a suboptimal outcome.

Reconstruction of seventeen full-thickness defects of the eyelids with twenty-two Hübner tarsomarginal grafts

In 1976, Hübner described a new technique to repair full-thickness defects of the eyelids. In 1993, we decided to adopt this simple and easily reproducible technique that guarantees restoration of the normal aspect of the margin. Subsequently, 17 eyelid reconstructions were performed on 13 patients, requiring the harvesting of 22 tarsomarginal grafts. No cosmetic or functional sequelae in the donor eyelids were observed. One or several functional complications were present in seven out of 17 reconstructed eyelids, including two cases of epiphora, one case of lagophtalmos and two cases of lid notch. Loss of the eyelids was observed in three cases out of six upper eyelid reconstructions and in nine cases out of 11 lower eyelid reconstructions. In all cases, the margin integrity was otherwise preserved. Very few simple techniques achieve that level of quality in the eyelid reconstruction process.

The maximal Hughes procedure

PURPOSE

To describe the use of oblique medial and lateral periosteal flaps with the Hughes tarsoconjunctival flap for the repair of maximal defects of the lower eyelid.

METHODS

A small prospective case series of eight patients requiring lower eyelid reconstruction following with maximal defect of the lower eyelid. The patients underwent a Hughes tarsoconjunctival advancement combined with oblique medial and lateral periosteal flaps, and were assessed for aesthetic outcome and surgical complications.

RESULTS

All patients had uncomplicated surgery. Outcomes assessed included corneal protection, eye closure, lower eyelid retraction, complications, and patient satisfaction. Eyelid contour and protection was excellent in all patients. Postoperatively, one patient had mild lower eyelid retraction, and in a second patient, medial ectropion with mild lower eyelid retraction developed that required subsequent revision.

CONCLUSIONS

The maximal Hughes procedure is a safe and effective procedure that may be performed with patients under local anesthesia and may avoid the need for more extensive techniques for surgical repair of maximal defects of the lower eyelid.